Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring.
Pharmacotherapy for mood disorders in pregnancy: a review of pharmacokinetic changes and clinical recommendations for therapeutic drug monitoring.
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DOI：
10.1097/jcp.0000000000000087
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发表时间：
2014-04
影响因子：
2.9
通讯作者：
Freeman MP
中科院分区：
文献类型：
--
作者：
Deligiannidis KM;Byatt N;Freeman MP
妊娠期情绪障碍的药物治疗通常因妊娠相关的药代动力学变化和剂量调整的需要而复杂化。本综述的目的是总结常用药物治疗心境障碍的围产期药代动力学变化的证据，讨论临床和治疗药物监测（TDM）的意义，并提出临床建议。检索MEDLINE/PubMed上索引的英文文献，以查找评价或描述妊娠或产后期间药代动力学变化或TDM的原始观察性研究（对照和非对照、前瞻性和回顾性）、病例报告和病例系列。妊娠相关的吸收、分布、代谢和消除的变化可能导致精神药物水平降低和可能的治疗效果，特别是在妊娠晚期。其机制包括1相肝细胞色素P450和2相尿苷二磷酸葡萄糖醛酸转移酶活性的变化、肝和肾血流的变化以及肾小球滤过率。治疗药物监测，结合临床监测，适用于围产期的三环类抗抑郁药和情绪稳定剂。在怀孕期间，一些常用的抗抑郁药和情绪稳定剂可能会发生实质性的药代动力学变化。可能需要增加抗抑郁药的剂量，包括西酞普兰、氯米帕明、丙咪嗪、氟西汀、氟伏沙明、去甲替林、帕罗西汀和舍曲林，尤其是在怀孕后期。由于围产期代谢的变化，锂、拉莫三嗪和丙戊酸也可能需要增加围产期剂量。建议对围产期情绪障碍进行密切的临床监测，并对三环类抗抑郁药和情绪稳定剂进行TDM。
Pharmacotherapy for mood disorders during pregnancy is often complicated by pregnancy-related pharmacokinetic changes and the need for dose adjustments. The objectives of this review are to summarize the evidence for change in perinatal pharmacokinetics of commonly used pharmacotherapies for mood disorders, discuss the implications for clinical and therapeutic drug monitoring (TDM), and make clinical recommendations. The English-language literature indexed on MEDLINE/PubMed was searched for original observational studies (controlled and uncontrolled, prospective and retrospective), case reports, and case series that evaluated or described pharmacokinetic changes or TDM during pregnancy or the postpartum period. Pregnancy-associated changes in absorption, distribution, metabolism, and elimination may result in lowered psychotropic drug levels and possible treatment effects, particularly in late pregnancy. Mechanisms include changes in both phase 1 hepatic cytochrome P450 and phase 2 uridine diphosphate glucuronosyltransferase enzyme activities, changes in hepatic and renal blood flow, and glomerular filtration rate. Therapeutic drug monitoring, in combination with clinical monitoring, is indicated for tricyclic antidepressants and mood stabilizers during the perinatal period. Substantial pharmacokinetic changes can occur during pregnancy in a number of commonly used antidepressants and mood stabilizers. Dose increases may be indicated for antidepressants including citalopram, clomipramine, imipramine, fluoxetine, fluvoxamine, nortriptyline, paroxetine, and sertraline, especially late in pregnancy. Antenatal dose increases may also be needed for lithium, lamotrigine, and valproic acid because of perinatal changes in metabolism. Close clinical monitoring of perinatal mood disorders and TDM of tricyclic antidepressants and mood stabilizers are recommended.